European practices of mentoring with young adults at risk of social disadvantage and school drop-out Grundtvig Learning Partnership

Stages of Change Model and Motivational Interviewing Implications for Counseling Young Adults Psih.IULIA LAZAR

Learning Objectives Describe Stages of Change Model. Recognize and assess stage in case studies. Describe the principles of motivational interviewing. Describe and use the motivational interviewing strategies. Practice doing motivational interviewing adapted to a particular stage.

Rationale for the topic Mentoring – relationship of support and guidance between an adult and a young person. Mentoring – relationship of support and guidance between an adult and a young person. In counseling young adults we often target behavioral change. In counseling young adults we often target behavioral change. Behavioral problems common in young adults : Behavioral problems common in young adults : - truancy and school drop out - truancy and school drop out - aggressive behavior and bulling - aggressive behavior and bulling - conduct problems - conduct problems - substance use ( drugs, smoking, alcohol ) - substance use ( drugs, smoking, alcohol ) - sexual risk behaviors - sexual risk behaviors - gang membership - gang membership - other health risk behavior (poor diet, sedentary behavior, life risking sports and hobbies etc.) - other health risk behavior (poor diet, sedentary behavior, life risking sports and hobbies etc.)

How does behavior change? Behaviors are learnt observable and measurable reactions. Behaviors are learnt observable and measurable reactions. Behaviors are determined by information processes (thoughts) primed/triggered by external or internal stimuli and maintained by their consequences ( positive or negative). Behaviors are determined by information processes (thoughts) primed/triggered by external or internal stimuli and maintained by their consequences ( positive or negative). The thoughts that determine behaviors refer to : The thoughts that determine behaviors refer to : 1) knowledge about how to do the behavior 1) knowledge about how to do the behavior 2) expectances about benefits of the behavior-motivation 2) expectances about benefits of the behavior-motivation 3) self efficacy about being capable of doing the behavior. 3) self efficacy about being capable of doing the behavior. To change behavior, the determinants ( triggers-stimuli and thoughts) and the consequences ( ex. positive reinforces ) must be both modified. To change behavior, the determinants ( triggers-stimuli and thoughts) and the consequences ( ex. positive reinforces ) must be both modified. When targeting behavior change we often promote deceleration of an undesired behavior and automatically acceleration of an incompatible desired behavior. When targeting behavior change we often promote deceleration of an undesired behavior and automatically acceleration of an incompatible desired behavior. In counseling, we often target cognitive change ( raising knowledge about the desired behavior, reducing perceived benefits for the undesired behavior, enhancing perceived benefits-motivation for the desired behavior and enhancing self efficacy about doing the desired behavior). In counseling, we often target cognitive change ( raising knowledge about the desired behavior, reducing perceived benefits for the undesired behavior, enhancing perceived benefits-motivation for the desired behavior and enhancing self efficacy about doing the desired behavior).

Exercise 1 : Objectives: reflect on how people change their behavior. reflect on the mentor s expectations for change. reflect on the mentor s expectations for change. Read the questions from your hand out and answer. What conclusions could we draw from the group ’s responses ? responses ?

Possible Conclusions: Behavioral problems are common for young people and adults. Behavioral problems are common for young people and adults. Behavioral change takes a long time. Behavioral change takes a long time. The pace of time is variable. The pace of time is variable. Knowing a behavior has bad consequences is not enough to motivate change. Knowing a behavior has bad consequences is not enough to motivate change. Relapse is the rule. Relapse is the rule. When mentoring/counseling young people there is a risk of having unrealistic expectations about the success of promoting behavioral change. When mentoring/counseling young people there is a risk of having unrealistic expectations about the success of promoting behavioral change. Unrealistic expectations can lead to frustration and burn out. Unrealistic expectations can lead to frustration and burn out.

Why learn about the Stages of Change Model and Motivational Interviewing ? More realistic expectations. More realistic expectations. Greater recognition of small accomplishments. Greater recognition of small accomplishments. Greater efficiency of interventions for behavioral change. Greater efficiency of interventions for behavioral change. Less frustration and burn out. Less frustration and burn out.

Stages of Change Model Useful theoretical framework for understanding how people intentionally change their risk behaviors and for implementing interventions that target behavior change. Useful theoretical framework for understanding how people intentionally change their risk behaviors and for implementing interventions that target behavior change. Developed by Prochaska J.O. and DiClemente C.C. starting from the 70 s, in health psychology. Developed by Prochaska J.O. and DiClemente C.C. starting from the 70 s, in health psychology. Principles: Principles: - Behavior change is a dynamic process. - Behavior change is a dynamic process. - People progress through stages of change. - People progress through stages of change. - Movement may be forward or backwards or even cyclical. - Movement may be forward or backwards or even cyclical. - When targeting behavior change, intervention should be stage appropriate. - When targeting behavior change, intervention should be stage appropriate.

Stages of Change

I. Pre-contemplation "Ignorance is bliss” Characteristics: not currently considering change. Goal for counseling : move to contemplation of change. Barriers: -Lack of knowledge of risks/consequences. -Low self-efficacy about adopting the desired behavior. -Contentment with present behavior.

Intervention appropriate to Pre-contemplation stage Validate lack of readiness for change. Acknowledge possible feelings of being pressured. Clarify: decision is theirs. Encourage re-evaluation of current behavior. Encourage self-exploration, not action. Offer knowledge about the risks/consequences. Personalize the risks/consequences. Use motivational interviewing.

II. Contemplation "Sitting on the fence" Characteristics: ambivalent about change; not considering change within the next month. Characteristics: ambivalent about change; not considering change within the next month. Goal for counseling: move to preparation for change. Goal for counseling: move to preparation for change. Barriers: Barriers: -Lack of knowledge of risks/consequences. -Low self-efficacy about adopting the desired behavior. -Contentment with present behavior. -Indecisiveness/ ambivalence.

Intervention appropriate to Contemplation stage Validate lack of readiness for change. Validate lack of readiness for change. Clarify: decision is theirs. Clarify: decision is theirs. Encourage evaluation of pros and cons of present behavior and behavior change. Encourage evaluation of pros and cons of present behavior and behavior change. Identify and promote new, positive outcome expectations. Identify and promote new, positive outcome expectations. Use motivational interviewing.

III. Preparation "Testing the waters" Characteristics: some experience with change and commitment to change; planning to act within 1 month Characteristics: some experience with change and commitment to change; planning to act within 1 month Goal for counseling: Goal for counseling: move to action, design plan for change. Barriers: Barriers: - Loss of commitment for change. - Lack of knowledge about options. - Difficulty in making decisions about plans for change.

Intervention appropriate to Preparation stage Praise the decision to change behavior. Praise the decision to change behavior. Identify and assist in problem solving : obstacles. Identify and assist in problem solving : obstacles. Help the person to identify social support. Help the person to identify social support. Verify that the person has underlying skills for behavior change. Verify that the person has underlying skills for behavior change. Encourage small initial steps. Encourage small initial steps. Use motivational interviewing.

IV. Action Characteristics: commitment to change; practicing new behavior for 3-6 months. Characteristics: commitment to change; practicing new behavior for 3-6 months. Goal for counseling: o Goal for counseling: optimize plan for change, maintain changes. Barriers: Barriers: - - Failure and disillusionment - Overconfidence

Intervention appropriate to Action stage Focus on restructuring cues and social support. Focus on restructuring cues and social support. Bolster self-efficacy for dealing with obstacles. Bolster self-efficacy for dealing with obstacles. Combat feelings of loss and insist on the long-term benefits of the new behavior. Combat feelings of loss and insist on the long-term benefits of the new behavior.

V. Maintenance Characteristics: continued commitment to sustaining new behavior ; post-6 months. Characteristics: continued commitment to sustaining new behavior ; post-6 months. Goal for counseling: maintaining a Goal for counseling: maintaining a stable, new lifestyle; attainment of original goals. Barriers: Barriers: - - Major losses and stresses in life. - Failure to attain original goals.

Intervention appropriate to Maintenance stage Plan for follow-up support. Plan for follow-up support. Reinforce internal rewards. Reinforce internal rewards. Discuss coping with relapse. Discuss coping with relapse. Discuss possible triggers for relapse. Discuss possible triggers for relapse.

VI. Relapse "Fall from grace" Characteristics: resumption of undesired behaviors; relapse is a normal, expected stage of behavior change. Characteristics: resumption of undesired behaviors; relapse is a normal, expected stage of behavior change. Goal for counseling Goal for counseling - Identify relapse. - Reframe relapse as an opportunity to learn. - Make a new plan for change.

Intervention appropriate to Relapse stage Evaluate triggers for relapse. Evaluate triggers for relapse. Reassess motivation and barriers. Reassess motivation and barriers. Plan stronger coping strategies. Plan stronger coping strategies.

VII. Termination/Exit Characteristics: Relapse is highly unlikely. New lifestyle/behavior is stable. Pre-contemplation about returning to old behavior.

Exercise 2. Exercise 2. Objective : recognizing the stage of change. Objective : recognizing the stage of change. Watch the videos. Watch the videos. Use the description of the stages from your hand out. Use the description of the stages from your hand out.

Assessing Stage of Change I. Interview/ discussion with the student. Open-ended questions: Open-ended questions: How do you feel about your [behavior]? How do you feel about your [behavior]? What do you think about your [behavior]? What do you think about your [behavior]? Closed questions: Closed questions: “ On a scale of 1 – 10, with 10 being 100% ready to take action, how ready are you to: go back to school, attend classes every day, stop drinking, lose weight, etc. ?" “ On a scale of 1 – 10, with 10 being 100% ready to take action, how ready are you to: go back to school, attend classes every day, stop drinking, lose weight, etc. ?"

"On a scale of 1–10, with 10 being100% ready to take action, how ready are you to (behavior) ?" means the person has very little intention to change – pre-contemplators means the person has very little intention to change – pre-contemplators. 5 – 7 means the person is ambivalent about changing – contemplation stage. 5 – 7 means the person is ambivalent about changing – contemplation stage. 8 – 10 means the person is very willing to take action – preparation stage. 8 – 10 means the person is very willing to take action – preparation stage. II. Self-report scales. University of Rhode Island Change Assessment Scale (URICA). Thirty-two-item scale. Thirty-two-item scale. Useful for adolescents and adults. Useful for adolescents and adults. Assesses attitudes toward changing problem behaviors. Assesses attitudes toward changing problem behaviors. Free online at: Free online at:

Motivational Interviewing A directive, client-centered counseling style that enhances motivation for change, by helping the patient/client clarify and resolve ambivalence about behavior change. A directive, client-centered counseling style that enhances motivation for change, by helping the patient/client clarify and resolve ambivalence about behavior change. The goal of Motivational Interviewing is to create and amplify discrepancy between present behavior and future personal goals. The goal of Motivational Interviewing is to create and amplify discrepancy between present behavior and future personal goals. Where I am Where I want to be Where I am Where I want to be

Stages of Change Model and Motivational Interviewing (MI) MI is thought to deliver the motivation required to move individuals through the different stages of change. Motivational interviewing is an excellent counseling style to use with clients who have no commitment to change (pre-contemplation, contemplation). MI has been found to be an effective ‘‘stand alone’’ intervention for many behavioral and emotional problems. (Burke et. al, 2003).

Strategies of Motivational Interviewing Avoid argument and direct confrontation. Express empathy through reflective listening. Develop discrepancy between the person‘s goals or values and their current behavior. Adjust to the person‘ s resistance rather than opposing it directly. Support self-efficacy and optimism.

1. AVOIDING ARGUMENTATION MI is collaborative vs. argumentative. MI is collaborative vs. argumentative. Arguments are counterproductive. Arguments are counterproductive. Defending breeds defensiveness. Defending breeds defensiveness. Resistance is a signal to change strategies. Resistance is a signal to change strategies. Labeling is unnecessary and should be avoided. Labeling is unnecessary and should be avoided. Threats should be avoided ( ex. “ things will turn bad for you if you continue doing…” Threats should be avoided ( ex. “ things will turn bad for you if you continue doing…”

2. EXPRESSING EMPATHY Empathy "is a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning" (Miller and Rollnick, 1991, p. 20) Being empathic means to develop and communicate an understanding of the individual’s situation and feelings around the behavior. ccept the person s ambivalence and pain of engaging in behavior that hinders goals. Being empathic also means to accept the person s ambivalence and pain of engaging in behavior that hinders goals. The mentor s attitude should be one of acceptance, but not necessarily approval or agreement with the behavior. The mentor s attitude should be one of acceptance, but not necessarily approval or agreement with the behavior. Empathy encourages a nonjudgmental, collaborative relationship. Empathy encourages a nonjudgmental, collaborative relationship. The key component to expressing empathy is reflective listening. The key component to expressing empathy is reflective listening.

Reflective listening Listen attentively the message then communicate back the meaning. You reflect back in the form of a statement rather than a question. ” It sounds like you think/feel/do...” ” You are feeling...” “ From what you are saying it seems that you…” There are three levels of reflective listening: 1) Repeating 2) Rephrasing 3) Paraphrasing

3. ROLLING WITH RESISTANCE Resistance is a legitimate concern for the mentor/counselor because it is predictive of poor outcomes and lack of involvement in the counseling process. One constructive view of the resistance is as a signal that the counseled person views the situation differently. One constructive view of the resistance is as a signal that the counseled person views the situation differently. You should respond by … Backing up Reflecting the person s frustration/resistance Working with the patient/client at the appropriate stage of change. Resistant responses can be quite normal during a typical counseling session.. Especially useful in Pre-contemplation, Contemplation, Preparation stages. Ways to react appropriately to client resistance.

4. SUPPORTING SELF EFFICACY Many young adults do not have a sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Many young adults do not have a sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. How to promote self efficacy? How to promote self efficacy? - Identify previous successes and strengths of the counseled person that can be applied to behavior change. - Identify previous successes and strengths of the counseled person that can be applied to behavior change. - Talk about how persons in similar situations have successfully - Talk about how persons in similar situations have successfully changed their behavior. changed their behavior. - Make affirmation about the person ; when it is done sincerely, affirmations support and promote self-efficacy; your affirmation acknowledges the difficulties the client has experienced. - Make affirmation about the person ; when it is done sincerely, affirmations support and promote self-efficacy; your affirmation acknowledges the difficulties the client has experienced. Especially useful in the Preparation, Action, and Maintenance stages, and also post Relapse. Especially useful in the Preparation, Action, and Maintenance stages, and also post Relapse.

5. DEVELOPING DISCREPANCY Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes and plans for the future. Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes and plans for the future. STEPS: STEPS: - Separate behavior from the person. - Separate behavior from the person. - Discuss pro and cons of the problematic behavior. - Discuss pro and cons of the problematic behavior. - Discuss conflict between negative consequences of behavior and important personal goals of the person. - Discuss conflict between negative consequences of behavior and important personal goals of the person. - Amplify and focus on this discordance until the person can articulate consistent concern and commitment to change. - Amplify and focus on this discordance until the person can articulate consistent concern and commitment to change. Especially useful in Pre -contemplation, Contemplation and Preparation stages. Especially useful in Pre -contemplation, Contemplation and Preparation stages.

SUMMARY Stages of Change Model- a theoretical framework for understanding intentional behavior change. Stages of Change Model- a theoretical framework for understanding intentional behavior change. When counseling young people with behavioral problems, always asses the stage of change. When counseling young people with behavioral problems, always asses the stage of change. When targeting behavioral change in counseling use stage appropriate counseling goals and techniques. When targeting behavioral change in counseling use stage appropriate counseling goals and techniques. Motivational interviewing – a directive, client-centered counseling style that enhances motivation for change. Motivational interviewing – a directive, client-centered counseling style that enhances motivation for change. Use the MI strategies when counseling young adults with or independent of stage assessment and behavior change intervention. Use the MI strategies when counseling young adults with or independent of stage assessment and behavior change intervention.

References Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843–861 Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self- change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. http: //